Paediatric difficult airway management: Difference between revisions

Paediatric difficult airway management (view source)

Revision as of 15:45, 12 February 2023

5,157 bytes added , 1 year ago

no edit summary

WikiSysop

Bureaucrats, Interface administrators, Administrators

3,690

edits

@@ Line 106: / Line 106: @@
 management in children. 2012. http://www.apagbi.org.uk/publications/apaguidelines</ref><sup></sup>
+== AIRWAY ASSESSMENT ==
+Proper airway assessment, proper planning for airway management,
+and the use of monitoring are essential basic principles for safe
+anaesthesia in children.
+Airway assessment may be considered in two parts:
+Will facemask ventilation be difficult?
+:• A tumour or abnormal face shape may prevent the facemask from
+sealing easily over the face.
+:• Syndromes associated with midface hypoplasia
+:• Children with severe obstructive sleep apnoea (e.g. tonsillar
+hypertrophy).
+Will intubation be difficult?
+Factors that may predict difficult intubation in children include:
+:• Mandibular hypoplasia e.g. syndromes such as Pierre Robin
+:• Poor mouth opening
+:• Obstructive sleep apnoea
+:• Stridor
+:• Syndromes associated with facial asymmetry. Note ear
+abnormalities are often associated (e.g. Goldenhar syndrome).
+Various tests and scoring systems have been suggested for use in
+adults. Many have a very poor sensitivity and/or specificity and are
+not validated in children. However, assessment of the following is
+essential. The anaesthetist may need some ingenuity to achieve these
+assessments in a small uncooperative child!
+:• Mouth opening
+:• Range of neck movement
+:• Mandibular hypoplasia - micrognathia makes intubation difficult.
+Assess the airway by observing the child in side view rather than
+from the front.
+:• Mandibular hyperplasia - ameloblastoma may cause jaw
+protrusion and can make laryngoscopy and intubation difficult
+:• Inspection of the oral cavity (e.g. for intraoral masses).
+The Mallampati score can be used for older children who are
+cooperative. Even though there is no validated scoring system in infants
+and young children, the anaesthetist must still make a risk assessment,
+and decide on the anticipated difficulty of intubation. This airway
+assessment must be documented in the anaesthetic record.<ref>World Health Organisation. Guidelines for Safe Surgery 2009. http://whqlibdoc.
+who.int/publications/2009/9789241598552_eng.pdf and http://www.who.int/
+patientsafety/safesurgery/en/</ref><sup></sup>
+== PLAN FOR AIRWAY MANAGEMENT ==
+After airway assessment, a structured plan for airway management
+is required before induction of anaesthesia. The plan must consider:
+:• Choice of airway e.g. facemask, supraglottic airway device or
+tracheal tube
+:• Mode of ventilation e.g. spontaneous ventilation or positive
+pressure
+:• Monitoring e.g. pulse oximeter (minimum); end tidal carbon
+dioxide.
+Due to a lower functional residual capacity (FRC) and higher
+metabolic rate, oxygen saturation falls much faster in infants and
+young children than adults. Preoxygenation before induction of
+anaesthesia establishes a reservoir of oxygen in the lungs by displacing
+nitrogen. This means a patient can remain oxygenated for longer than
+otherwise expected, which gives more time to address unexpected
+airway problems. Therefore preoxygenation is an important part of the
+airway management plan and should form part of normal anaesthetic
+practice wherever possible, even in children.
+== THE UNEXPECTED DIFFICULT AIRWAY ==
+Problems with airway management may be due:
+:1. Difficult mask ventilation
+:2. Difficult tracheal intubation
+:3. Can’t intubate and can’t ventilate (CICV).
+The first step is to administer 100% oxygen and call for help. Another
+pair of hands is always useful.
+The next step is to consider – is this a problem with the equipment or
+the patient? All equipment should be checked prior to induction of
+anaesthesia to minimise the chance of equipment failure.
+===1. Difficult mask ventilation===
+A simple algorithm for the management of difficult mask ventilation
+is given in Figure 1: Difficult mask ventilation algorithm. http://
+www.apagbi.org.uk/sites/default/files/images/APA1-DiffMaskVent-
+FINAL.pdf
+====Difficult mask ventilation – equipment problems====
+Equipment failure should be excluded quickly – check the mask,
+circuit, and oxygen supply. Always have a self-inflating bag available
+in case of equipment problems.
+====Difficult mask ventilation – patient factors====
+These can be divided into anatomical or functional problems.
+Anatomical problems associated with difficult mask ventilation may
+be due to poor head positioning, large adenoids/tonsils, or due to
+airway obstruction from cricoid pressure (if used).
+Functional problems may arise in the upper or lower airways. Upper
+airway obstruction may be due to inadequate depth of anaesthesia and
+laryngospasm; lower airway problems include inflation of the stomach
+(very common in infants), bronchospasm or chest wall rigidity (rare).
+====Management of difficult mask ventilation:====
+:• Adjust the head position – does the child need a head roll (or
+should the head roll be removed)
+:• Use simple airway opening manoeuvres (chin lift, jaw thrust)
+:• Apply positive end expiratory pressure (PEEP)
+:• Adjust cricoid pressure if it has been used
+:• Insert an oropharyngeal airway (if the patient is deep enough)
+:• Increase depth of anaesthesia
+:• Ventilate using a two-person technique (one holding the mask with two hands, the other ventilating by squeezing the bag)
 == REFERENCES ==